Unfiltered radiation therapy

ABSTRACT

This is a new technique of producing high energy X-rays for radiation therapy at a patient&#39;s level. The dose delivery system uses a linear accelerator with no flattening filter. The technique improves patient radiation therapy by reducing radiation scattered to surrounding normal tissue and reducing electron contamination. It increases dose rate to shorten treatment time. The flattening filter reduces the efficiency of the beam by reducing the fluence and increasing scattered radiation. This technique involves removal of the flattening filter. It uses inverse planning to shape the dose distribution.

CROSS REFERENCE TO RELATED APPLICATIONS

This divisional application claims the benefit of U.S. provisionalpatent application: Ser. No. 60/775,677, filed Feb. 21, 2006; PCTapplication serial no. PCT/US2007/04403, filed Feb. 20, 2007; and U.S.utility patent application Ser. No. 12/224,015, filed Oct. 13, 2010.

TECHNICAL FIELD

This invention relates to a method of performing radiation therapy. Morespecifically the invention relates to a new technique in IMRT conformalgamma radiation dose delivery using a linear accelerator with noflattening filter. The new technique improves patient radiation therapyby reducing radiation scattered to surrounding normal tissue without afilter.

BACKGROUND OF THE INVENTION

Intensity modulated radiation therapy (IMRT) is a treatment method forcancer patients requiring radiation treatment. IMRT is an extremelyprecise method of treatment delivery where the radiation dose conformsto the target and avoids the surrounding critical structures. Ratherthan having a single large radiation beam pass through the body, withIMRT the treatment is delivered from various angles and the intensity ofthe radiation beam is varied across the treatment area.

The radiation is effectively broken up into thousands of tinypencil-thin radiation beams. With millimeter accuracy, these beams enterthe body from many angles and intersect on the cancer. This results in ahigh radiation dosage to the tumor and a lower radiation dose to thesurrounding healthy tissues.

One method for modulating the intensity of the radiation beam is basedupon moving a multi-leaf collimator (MLC) in and out of radiation beamfrom the radiation treatment machine. An MLC comprises a plurality ofthin width mechanical blades or leaves, which are individuallycontrolled by miniature motors and mechanical drive linkages. A computercontrols the miniature motors for driving the individual blades in andout to shape the radiation beam. An advantage of an MLC based IMRTtreatment machine is that the same MLC can be automatically controlledto support the individual needs of each patient receiving radiationtreatment. In other words, the MLC is reconfigured for each new patient.

Linear accelerators have for decades come with a photon flatteningfilter to make the photon profile of planar fluence and thus, the dosedistribution more uniform. These filters have then resulted in fluenceattenuation and contamination of the beam. Now in the age of techniquessuch as intensity modulated radiation therapy (IMRT) the function of theflattening filter becomes redundant and the flattening filter now merelyreduce the efficiency of the beam by reducing the fluence and increasescattered radiation.

Other objects and advantages of the present invention will becomeapparent to those skilled in the art upon a review of the followingdetailed description of the preferred embodiments and the accompanydrawings.

SUMMARY OF THE INVENTION

Our technique involves removal of the flattening filter for complextreatments and using inverse planning along with multi-leaf collimatorsto shape the dose distribution.

With the flattening filter removed the dose rate is increased and helateral scatter is reduced. This improves patient treatment by reducingdose to the normal tissue surrounding the target and also reducestreatment times. The flattening of the beam profile is redundant intechniques such as IMRT since the planar fluence is controlled by themulti-leaf collimator (MLC). For many modern linear accelerators,removal of the flattening filter requires no physical modification ofthe unit since the flattening filter can simply be mechanically movedout of the beam path.

This new technique is in IMRT and 3D conformal gamma radiation dosedeliver using a linear accelerator with no flattening filter. Thetechnique improves patient radiation therapy by reducing radiationscattered to surrounding normal tissue and reducing electroncontamination. It increases does rate to shorten treatment time.

Linear accelerators have for decades come with a photon flatteningfilter to make the photon profile of planar fluence to make the dosedistribution more uniform. These filters, however, have resulted influence attenuation and contamination of the beam.

Now in the age of techniques such as intensity modulated radiationtherapy (IMRT) the function of the flattening filter becomes redundant.The flattening filter now merely reduces the efficiency of the beam byreducing the fluence and increasing scattered radiation.

BRIEF DESCRIPTION OF THE DRAWINGS

FIGS. 1(a) and 1(b) show Monte Carlo and water phantom measurements ofthe CAX percent depth-dose for 6 MV and 10 MV.

FIGS. 2(a) and 2(b) show Monte Carlo and water phantom measurements oftransverse profiles at depths d_(max) and 10 cm, for 6 MV and 10 MV.

FIG. 3 shows a comparison between Monte Carlo and measured data for a 6MV 10×10 cm² beam.

FIG. 4 shows a Monte Carlo computed transverse cross-plane profiles at adepth of 1.6 cm for a 6 MV filter free photon beam of field size rangingfrom 2×2 to 30×30 cm².

FIGS. 5(a) and 5(b) shows a comparison between Monte Carlo simulationsfor a standard, flattened and an unflattened 6 MV and 10 MV 10×10 cm²beam at d_(max). All profiles are normalized to the central axis does ofthe standard beam to show the effect on the CAX dose of removing theflattening filter.

FIGS. 6(a) and 6(b) shows a Monte Carlo percent depth-dose curvescomparing the standard flattened 6 MV and 10 MV beams to the equivalentfilter-free beams.

FIGS. 7(a) and 7(b) show a photon fluence spectra for a 6 MV beam and a10 MV beam showing the effect of removing the photon flattening filter.

FIG. 8 shows a comparison of absolute does obtained from simulations of2×2, 10×10 and 30×30 cm² fields. The simulations shown here were for a 6MV beam at a depth of 1.6 cm.

DETAILED DESCRIPTION OF THE INVENTION

IMRT (Intensity Modulated Radiation Therapy) is rapidly becoming acommon treatment modality with a recent study claiming that it is usedby a third of the radiation oncologists in the United States. The moderntreatment machines are designed with dynamic MLC and IMRT-ready systemsintegrated into them but many of the current linear accelerators stillused today, have the MLC as an add-on. In either case the linearaccelerator is designed such that IMRT treatments and standardtreatments can be carried out on the same unit. The conventional 3Dconformal therapy treatment requires a flat beam because generally dosecompensation to achieve uniformity within target volume for eachindividual beam is not performed. However, in generating IMRT treatmentplans, the planner ends up with a non-uniform density matrix to deliverthe desired dose with the target volume, and spare the surroundingnormal or critical structures. To achieve this goal, a flat beam is notrequired. Modulation of beam during IMRT planning and delivery isperformed through segmented fields and many beamlets within the deliveryport and in fact thinking out side of convention, one would see theadvantages in having a cleaner beam that does not need to suffer all thescattering through a thick chunk of metal, namely the flattening filter.It is therefore, expected that removal of the flattening filter wouldlead to better IMRT treatments due to the reduction in lateral photonscatter and the increase in central axis photon fluences. Morespecifically, by moving the flattening filter out of the path of thebeam solely for IMRT treatments, higher dose rates and sharper, moregeometrically defined fields can be expected thus leading to better IMRTplans and treatments. The deleterious properties of the flatteningfilter care caused by the increased lateral scatter and the decreasedcentral axis fluence that the filter produces. In the special case ofIMRT, where fluence is varied by a combination of MLC movements and beammodulation at the patient level, the filter is no longer required. Thishas been shown for the specific case of tomotherapy; a dedicated IMRTsystem. Here we show Monte Carlo simulations of radiationcharacteristics for the more general case of a linear accelerator.Preferably, the higher dose rates are X-rays ranging from 4 MV to 25 MV.

Methods and Materials

Monte Carlo Simulations of an Elektra SL-25

Monte Carlo simulations were carried out using the BEAMnrc code. Usingan Elektra precise model SL-25 photon beams of 6 MV and 10 MV energieswere initially modeled and commissioned by comparing the simulations todata measured using a Welhofer (Scanditronix Wellhofer) scanning waterphantom. In the models the head of the accelerator was broken down intocomponent modules, namely the target, primary collimator, flatteningfilter, monitor chamber, mirror, MLC and X and Y jaws. An additionalcomponent was used to simulate the air gap between the exit of theaccelerator and the water phantom surface, where the phase space planewas located. The energy cutoffs for transport were set as ECUT=0.7 MeV,PCUT-0.01 MeV and global electron cut-off-2.0 MeV. Electron rangerejection and selective Bremsstahlung splitting were used, with SBSparameters N_(min)=10 nd N_(max)=100. Russian roulette and photonforcing were not employed. The phase space file created at the plane 100cm from the source was then used as the input for the phantom, simulatedusing the DOSXYZarc code. 400×10⁶ histories were used for the simulationof the accelerator. For the DOSXYZ phantom, 200×10⁶ histories were usedfor all field sizes, resulting in adequate statistics for the largerfield sizes.

Both depth dose and transverse profiles depend greatly on the propertiesof the electron beam as it strikes the photon target. The parameters ofimportance are the mean electron energy, the energy spread and thespatial distribution of the beam. For the 6 MV and 10 MV beamsrespectively, the electron energy used was 6.50 MeV and 9.50 MeV, theenergy spread was 1.0 MeV and 0.8 MeV FWHM and the radial distributionwas 0.11 cm and 0.10 cm FWHM. Depth dose curves obtained from thesesimulations deviated less than 1% in the region of dose-maximum and lessthan 5% at all other depths, when compared to water phantommeasurements.

Once the Monte Carlo simulation was found to match the measured data toadequate levels, the flattening filters were removed from both of the 6MV and 10 MV beam models. All other parameters remained unchanged.

Measurements Made in Water.

All measurements were made at 100 cm SSD in a Welhofer scanning waterphantom, with a 0.1 cc ionization chamber. Both 6 MV and 10 MV beamswere studied for comparison with the Monte Carlo simulations. After theMonte Carlo model commissioning data was obtained the 6 MV and 10 MVflattening filters were removed from the primary rotating carousel inthe head of the accelerator. This left a hole in the carousel which thephoton beam could pass through. Depth-ionization profiles, transverseinline (gun-target direction) and cross-plane profiles were measured atd_(max) and 10 cm. Depth dose profiles were measured to a depth of 30 cmand normalized to the maximum chamber reading on the central axis.Transverse profiles were measured in the inline and cross-planedirections for field sizes ranging from 5×5 to 30×30 cm². These profileswere also normalized to the maximum chamber reading on the central axis.

Results

Monte Carlo Model Commissioning

As mentioned, Monte Carlo simulations of the standard, flattened 6 MVand 10 MV beams where carried and they matched well with the measureddata obtained with the scanning water phantom. The purpose of thesemeasurements was to show that the Monte Carlo models accurately matchthe measurements of dose performed in the water phantom.

FIGS. 1(a) and 1(b) show Monte Carlo and water phantom measurements ofthe CAX percent depth-dose for 6 MV and 10 MV. Central axis percentdepth-dose profiles for a 10×10 cm² field at 100 cm SSD are shown for 6MV and 10 MV, with the experimental measurements shown as solid pointsand the Monte Carlo model shown as hollow points. Transverse profiles ofa 30×30 cm² field were also obtained for comparison of the flatness andsymmetry of the Monte Carlo models with respect to the measured data.

FIGS. 2(a) and 2(b) show 6 MV and 10 MV Monte Carlo calculatedtransverse profiles for the inline direction at depths of d_(max) and 10cm, compared to the measured data. A good agreement between measured andMonte Carlo modeled data was found in all cases.

FIG. 3 shows a comparison between Monte Carlo and measured data for a 6MV 10×10 cm2 beam. The top two curves are for a depth of 1.6 cm(d_(max)) and the bottom two curves are for a depth of 10 cm.

Monte Carlo Modelling of a Non-Flat Beam

Simulations were then carried out without the filter and compared todata measured after the flattening filters had been removed from theprimary filter carousel of the Elekta accelerator. The purpose of thesemeasurements was to verify the accuracy of the Monte Carlo models toaccurately simulate a beam without the flattening filter. A comparisonfor the cross-plane profiles is shown in FIG. 3.

Not shown are the comparisons between the inline (gun-target) directionmeasured and Monte Carlo profiles. These measured transverse profileshad poor symmetry and this was believed to be due to difficulties ofsteering the beam after removal of the flattening filter. It can beconcluded from FIG. 3 that the Monte Carlo models of filter free 6 MVand 10 MV beams were shown to accurately match the measured data.Simulations were then carried out for various field sizes ranging from2×2 cm² to 30×30 cm². The graph below shows the transverse profilesobtained at 1.6 cm depth for a 6 MV beam without a flattening filter.The curves in FIG. 4 are all normalized to the CAX dose of the 10×10 cm²field.

FIG. 4 shows Monte Carlo computed transverse cross-plane profiles at adepth of 1.6 cm for a 6 MV filter free photon beam of field size rangingfrom 2×2 to 30×30 cm².

The next step was to compare the Monte Carlo models of the flattened andunflattened beams. FIG. 5 shows Monte Carlo calculated transverseprofiles and the effect on the central axis (CAX) dose of removing theflattening filter. It was found that for the 6 MV photon beam of 10×10cm² field size the CAX dose was increased by a factor of 2.35 with thefilter removed, compared to the standard flattened beam. This figurealso shows the CAX dose was increased by a factor of 2.35 with thefilter removed, compared to the standard flattened beam. This figurealso shows the CAX dose for a 10×10 cm² 10 MV beam with and without theflattening filter. In this case, since the 10 MV flattening filter forthe Elekta is more substantial in terms of mass of material used the CAXdose without the filter is 4.18 times higher than the standard flattenedbeam.

FIGS. 5(a) and 5(b) show a comparison between Monte Carlo simulationsfor a standard, flattened and an unflattened 6 MV and 10 MV 10×10 cm²beam at d_(max). All profiles are normalized to the central axis dose ofthe standard beam to show the effect on the CAX dose of removing theflattening filter.

C. Quantification of Beam Flatness

The flatness of each transverse profile was calculated using thevariation over the mean at 80% of the field size, with the equation,

${flatness} = {100 \times \frac{D_{\max} - D_{\min}}{D_{\max} + D_{\min}}}$

For the 6 MV simulation of a 10×10 cm² beam, the flatness at d_(max) was2.37% and 6.21% for the flattened ad unflattened beam, respectively.Similarly, at 10 cm depth the equivalent percentages were 1.88% and5.77%.

For the 10 MV simulations, flatness percentages of 3.96% and 7.71% wereobtained at depths of 2.3 cm (d_(max)) and 10 cm for the standard andunflattened beam, respectively. At 10 cm depth flatness was calculatedto be 2.92% for the flattened beam and 8.39% for the unflattened beam.

D. Dose on the Central Axis

FIGS. 6(a) and 6(b) show Monte Carlo percent depth-dose curves comparingthe standard flattened 6 MV and 10 MV beams to the equivalentfilter-free beams. The faster decrease in dose with depth for thefilter-free beam is consistent with a softer central axis beam.

Depth dose curves on the central axis were also obtained fromsimulations of the flattened and unflattened 10×10 cm2 6 MV and 10 MVbeams. The dose deposited at depths greater than d_(max) was found todecrease more rapidly with the filter removed. This is due to the factthat, with the filter removed the beam in the region of the central axisis no longer hardened by the filter. The faster decrease in dose withdepth is consistent with a softer central axis beam. To investigate theeffect of the flattening filter on the photon energy spectrum ananalysis of various phase space files with the program BEAMDP wasperformed. Photon fluence as a function of photon energy was graphed forthe filter free beams versus the standard Beams. As expected, the photonfluence per unit energy is significantly greater for the filter freebeam, especially in the region of the peak photon energy.

FIGS. 7(a) and 7(b) show photon fluences spectra for a 6 MV beam and a10 MV beam showing the effect of removing the photon flattening filter.FIG. 7 shows the photon fluence spectra across a 10×10 cm² field forboth the 6 MV and the 10 MV beam. In both cases the peak photon energyis increased by removing the flattening filter, showing that theflattening filter has the effect of hardening the beam. For the 6 MVbeam the peak energy with and without the flattening filter are 0.48 MVand 0.33 MeV respectively. Similarly, for the case of the 10 MV beam,where the design of the flattening filter leads to a greater beamhardening effect, the peak photo energies are 1.13 MeV and 0.33 MeV forthe standard beam and the filter free beam.

E. Out of Field Dose

With the flattening filter removed, one would expect the amount oflateral photon scatter to decrease, the effect being that the dose at apoint outside the field would be reduced. To investigate this effect acomparison between the relative dose at and beyond the edge of theradiation field was made between simulations made of a 6 MV beam withand without the flattening filter. Simulations were run for a 6 MV beamfor various field sizes ranging from 2×2 cm² to 30×30 cm². In all casesthe dose at the edge of the field was greater for the filter-free beam.In FIG. 8 below, 2×2 cm², 10×10 cm² and 30×30 cm² fields are shown for aflattened and filter-free 6 MV beam. It can be seen that, in the wingsof the profile the relative dose for the filter-free beam is greaterthan that of the standard field in all cases. The profiles below are ata depth of 1.6 cm. The same profiles at a depth of 10 cm showed the sameeffect; the out of field dose being higher for the filter free beam.

FIG. 8 is a comparison of absolute dose obtained from simulations of2×2, 10×10 and 30×30 cm² fields. The simulations shown here were for a 6MV beam at a depth of 1.6 cm. For each field size a profile of theflattened beam and the unflattened beam are shown so that the dose atthe edges of the radiation field can be compared. It can be seen thatfor all field sizes the dose at the edge of the field is greater for thefilter-free beam.

To quantify the out of field dose were considered a point 2 cm outsideof the field (e.g. at an off axis distance of 3 cm for a 2×2 cm² field)and took the average of the relative doses for the voxels to the rightand left of the central axis. The table below shows the relative dose(the normalization is with respect to the CAX dose for the standard,flattened beam for that field size) at a point 2 cm outside theradiation field, for both the flattened and unflattened 6 MV beams. Allprofiles considered here are at a depth of maximum dose.

TABLE 1 Relative Dose (0%) with filter No filter 2 × 2 cm² 0.63 1.10 10× 10 cm² 2.86 4.55 30 × 30 cm² 6.03 7.64Table 1. Shows a comparison of out of field relative dose for variousfield sizes. For each field size the relative doses is given at a pointoutside or on the edge of the radiation field.

CONCLUSIONS

With flattening filter removed, the photon beams will not suffer theremarkable scattering that they will go through otherwise, resulting ina much cleaner beam at the patient's level. The conventional treatmentsrequiring a flat photon beam are not necessary for IMRT treatments asthe beams are modulated to achieve dose uniformity within the targetvolume. In fact the fluence maps as generated from a beam end up beingvery nonuniform for IMRT cases. The substantial increase in dose ratefrom a flattening filter free accelerator is significant in delivering aless contaminated beam at much shorter times. The computed depth doseplots for both 6 and 10 MV photon beams indicate that by removing theflattening filter out of the beam, better dose fall off beyond depth ofmaximum dose is achieved. On the other hand, because of a less hardenedbeam, the point of maximum dose ate depth will get closer to the surface(1-2 mm for 6×, and 2-3 mm for 10×). The out of field dose is aphenomenon that requires further study and will be discussed in detailin future works, but the measured and computed dose profiles intreatment fields indicate less scatter, significantly higher photonfluence, and overall a cleaner beam to be used for the IMRT treatment.The better fall-off of the dose beyond depth of maximum dose in aflattening free accelerator is also another indication to cleaner beamswhen filter is removed. The quantities of scatter and lower energyphotons contributing to dose depth is directly proportional to theenergy of the beam and is considerable for clinical photon beams.

Modifications

Specific compositions, methods, or embodiments discussed are intended tobe only illustrative of the invention disclosed by this specification.Variation on these compositions, methods or embodiments are readilyapparent to a person of skill in the art based upon the teachings ofthis specification and are therefore intended to be included as part ofthe inventions disclosed herein.

The above detailed description of the present invention is given forexplanatory purposes. It will be apparent to those skilled in the artthat numerous changes and modifications can be made without departingfrom the scope of the invention. Accordingly, the whole of the foregoingdescription is to be construed in an illustrative and not a limitativesense, the scope of the invention being defined solely by the appendedclaims.

We claim:
 1. A method for producing high energy X-rays for radiationtherapy at patient's level comprising the steps of: using a linearaccelerator without a flattening filter to provide a high radiation dosehaving a dose distribution; wherein the radiation dose is high energyX-rays ranging from 6 MV to 25 MV; using inverse planning to shape thedose distribution, increase dose rate and shorten treatment time; andradiating a patient in need of radiation therapy with the shapedradiation field.
 2. A method according to claim 1 including the step ofimproving patient radiation therapy by reducing radiation scattered tosurrounding normal tissue and reducing electron contamination.
 3. Amethod according to claim 1 including the step of delivering a lesscontaminated radiation beam at shorter treatment times.
 4. A methodaccording to claim 1 including the step of delivering a radiation beamwith higher photon fluence at the patient's level.
 5. A method accordingto claim 1 including the step of delivering a cleaner radiation beam atthe patient's level.
 6. A method according to claim 1 wherein the stepof removing the flattening filter reduces lateral scatter.
 7. A methodaccording to claim 1 including the steps of: controlling planar fluencein the radiation source with a multi-leaf collimator (MLC); and inversetreatment planning to achieve uniformity within a target volume for theradiation beam without a flattening filter.
 8. A method according toclaim 1 wherein the linear accelerator is an IMRT capable radiationaccelerator.
 9. A method according to claim 1 wherein the MLC is used toachieve uniformity that conforms to convention 3D therapy treatments.10. A method according to claim 1 including the step of varying fluencewith a combination of MLC movements in and out of radiation field toproduce beam modulation at the patient level.
 11. A method according toclaim 1 wherein the radiating delivers a 3D conformal gamma radiationdose to a treatment zone at the patient's level.